Indeed, Lina Hellström (Linnaeus University, Kalmar, Sweden) and team believe that medication reconciliation should be performed routinely for all patients being admitted to hospital.

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Hellström's team undertook a descriptive study within two medical wards in a Swedish hospital. Over a 1-month period, a clinical pharmacist assessed each patient shortly after admission to develop a comprehensive pre-admission medication list.

"The pre-admission medication list identified by the pharmacist was regarded as the most accurate list available since it was based on all available information sources and had been compiled according to a well established, systematic method," explain the researchers.

The pharmacist then reviewed each patient's medication list, as documented in the hospital electronic health record (EHR), and compared this with the pre-admission list.

Medication reconciliation was conducted once for each patient and took on average 32 minutes per patient via interview and 15 minutes if no interview was conducted, Hellström et al note in the open-access journal BMC Clinical Pharmacology.

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A total of 670 patients underwent medication reconciliation and were included in the analysis. Most patients were aged over 80 years and 66% had been prescribed six or more drugs for regular use prior to admission.

The clinical pharmacists identified a total of 1136 discrepancies between the pre-admission and hospital medication lists, affecting 420 patients. The mean number of discrepancies was 1.7 per patient overall and 2.7 per affected patient.

The discrepancies were classified into four groups: Omission of a drug (62%), dose too high (13%), dose too low (12), and additional drug (12%).

The pharmacist recommended correction of the discrepancy in 71% of cases, 70% of which were acted upon by the physician. Overall, 93% of medication errors resulted in correction of the hospital EHR lists, as a result of either the pharmacist's suggestion or the physician's initiative.

Hellström et al then performed a multivariate analysis, which identified two significant independent predictors for medication reconciliation errors: the number of drugs at admission (odds ratio [OR]=1.10 for each additional medication) and living in one's own home without any care service before admission (OR=1.58 versus living in a care home).

The authors conclude that, in this population of mainly older patients, around 50% were affected by errors in the medication history on hospital admission, "which highlights the importance of introducing processes for ensuring that the medication lists are accurate and complete as soon as possible after admission."

They write: "More research is needed, particularly to uncover the reasons for the possible impact of pre-admission care services on medication errors. In general, we believe that systematic medication reconciliations should be conducted in all patients admitted to hospital."